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Chapter 7 Human Errors and River Navigation
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### 第七章 各级人员的人为疏失 (Chapter 7 Human Errors Across All Ranks)
鉴於海事产业独特且恶劣的作业环境，海上事故往往被归因於不可避免的必然。诸如恶劣天气（暴风雨、巨浪、强风）、航行危险（浅水区、航行盲区、吃水限制），以及船舶本身的物理局限性（庞大的体积、迟缓的操纵性、超重货物带来的惯性动能）等挑战，统称为不可抗力（force majeure）——即考验船员与设备的不可避免之自然力量。面对海上如此多的变数，理论上是无法达到「零事故」纪录的。
然而，这些挑战并不代表人类束手无策。正如一位液化天然气（LNG）船公司的经理对其继任者所建议的，约有 90% 的海事事故源於人为因素：其中约 60% 来自直接疏失（误判或程序失误），30% 来自间接的人为要素问题（培训不足或组织文化问题）。对於 LNG 船这类高风险船舶而言——如桑吉号（Sanchi）碰撞等悲剧所警示——即使是微小的疏失也可能演变成灾难性的后果。虽然其他船型或许能承受偶发的小事故，但根植於人为疏失的事件对所有海事领域均构成普遍的威胁。
#### 疏失的文化建构 (The Cultural Construction of Error)
疏失的概念并非生来固有的，而是由社会与文化所建构。图 7-01 展示了与人为疏失相关的六个认知要素——即注意力、记忆力和决策等大脑功能的基本层面。当其中任何一项出现偏差（例如因注意力不集中或风险评估失误），就可能发生错误或违规行为，且往往需要耗费大量资源才能纠正。
文化规范进一步塑造了人们对疏失的看待与容忍程度。在某些社会中，对成年子女提供长期支持被视为理所当然的义务；而在其他社会中，这可能被视为过度溺爱。在极端的文化或意识形态背景下，外人视为错误的行为（例如被冠上道德崇高名义的高风险行为）可能在特定群体内部被常态化，从而导致巨大的牺牲。在海事环境中，船员因工作场所文化而形成的根深蒂固的例行公事或习惯，可能会掩盖风险，使偏离规范的行为看起来毫无问题。文化扮演著群体「集体记忆」的角色，使原本可能被标记为危险的行为变得合理化。
#### 船上海事文化的缺口 (Gaps in Onboard Maritime Culture)
当前的船上海事文化揭示了基础安全实务中的重大缺口，营造出一个危险的环境。基本技能（例如严谨的目视了望程序与熟练的雷达航行）已在整个行业中逐渐退化。尽管持有合格证书，许多值班航行员（OOW）和船长的准备工作仍未达标准，缺乏完整的情境意识。由於麻痹大意（complacency）以及「其他人也是这样操作」的心态，船员和公司往往无视这些风险——即使已有大量的出版物、指南和模拟器培训课程可供利用。
令人担忧的是，即使人员获得了适当的技能与经验，人类易犯错的本质依然存在。疲劳、过度自信或根深蒂固的习惯等因素都会削弱警觉性，导致关键时刻发生疏失。这反映了更广泛的「风险常态化」文化：当不良做法成为日常例行公事时，它们就不再被视为偏离规范。如果没有积极地去培养责任感、正念与持续改进，可预防的事故循环将会持续下去。
#### 缓减建议 (Recommendations for Mitigation)
为解决这些人为因素，海事组织应优先开展符合 IMO 标准的「人为要素（Human Element）」培训，包括疲劳管理（依据 STCW 公约）以及结合目视、雷达和自动化工具（如 AIS 和 ARPA）的复合技能。鼓励建立不互相指责的「公正文化（Just Culture）」以促进错误通报，定期进行驾驶台团队模拟演练，并开展文化审计以挑战麻痹大意的现象。透过整合这些做法，业界可以降低 90% 的人为疏失统计数据，朝向更安全的作业迈进。
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### 7.1 人为疏失：决策过程中的个人疏失 (Individual Errors in the Decision-Making)
人为疏失是人性中不可避免的一部分，但理解其类型、根本原因和缓减策略，对於包括海事作业在内的各个行业至关重要，以预防事故、提升安全性并优化效能。当行动或决策偏离预期结果时，就会发生这些疏失，这通常源於认知、情感或系统性的脆弱性。在驾驶台单个人的决策背景下，疏失可分为六种类型，每种类型都与不同的认知过程相关。这些如图 7-01 所示，并且经常在航行等高风险环境中相互作用。
1. **知识相关疏失 (Knowledge-Related Errors)：** 源於短期记忆（STM）的缺口或不准确，阻碍了对自身知识库的存取（例如在压力下遗忘关键程序，如在紧迫局面中忽视了避碰规则 COLREG）。
2. **情感相关疏失 (Emotion-Related Errors)：** 当高涨的情绪（如压力、恐惧或过度自信）压倒理性判断并干扰认知功能时发生（例如紧急情况下引发恐慌的决策，或平静航程中因麻痹大意而跳过安全检查）。
3. **注意力相关疏失 (Attention-Related Errors)：** 由注意力不集中引起，损害了执行任务所需的程序性记忆（例如在监控多个雷达目标时因分心、疲劳或注意力分散而遗漏航行警告）。
4. **技能相关疏失 (Skill-Related Errors)：** 源於应用与已学技能相关的长期记忆（LTM）时存在缺陷，通常是由於练习不足、培训过时或未能适应新程序所致。例如：
* 因不熟悉分道航行制（TSS）中更新的规程而误判船舶的操纵。
* 错误应用依据过时标准教授的避碰技巧，导致无效的转向。
5. **直觉相关疏失 (Intuition-Related Errors)：** 源於过度依赖透过习惯养成的自动化直觉思维（例如因对例行公事的盲目自信、时间紧迫或冲动的「突发奇想」决策，如在繁忙水域未经全面评估即改变航向，而跳过检查表步骤）。
6. **文化相关疏失 (Culture-Related Errors)：** 根植於文化或组织架构内的集体长期记忆中，其中被常态化的做法在群体内部被视为「正确」，但在更广泛的背景下可能构成疏失（例如同侪间对安全规程持麻痹大意态度，如在熟悉航线上容忍放松了望警觉）。
#### 图 7-01 记忆与人为要素图表 (Memory and Human Element Chart)
人类的记忆系统由三个核心部分组成：感官记忆（感官输入的短暂初始储存）、短期记忆（暂时保持与操作，常称为工作记忆）和长期记忆（知识与经验的永久储存）。认知过程可以是可言语化的（意识到的且可描述的）或非言语的（自动的与无意识的）。许多行动往往是在无意识中执行的，依赖程序性记忆（技能的肌肉记忆），而非需要意识解释的陈述性记忆（事实或情境知识）。这解释了为什么重复性的任务随著时间推移会变得自动化。
当在这种无意识模式下正确执行时，这些行动会形成有益的习惯——想想一位经验丰富的轮机员反射性地进行例行检查，从而提高效率与安全性。相反，当在无意识层面执行不当，则可能导致无意注意疏失（inattentional errors，例如因根深蒂固的麻痹大意而跳过关键安全步骤，可能在高风险的海事作业中引发疏忽）。*(注：在实际驾驶台作业中，「无意注意疏失」的概念可以更广泛，包括压力下的优先顺序混乱或漏掉交叉覆核。以您观察到的具体、重复出现的驾驶台情境来举例说明可能会有所帮助。)*
在此基础上，我们的认知努力在三个不同的层面上运作，每个层面都会影响任务的执行方式，以及在船舶驾驶台等动态环境中可能出现疏失的地方：
* **无意识（程序性记忆）：** 像走路或进食等任务依赖长期程序性记忆——在没有意识思考的情况下自动执行的习惯性动作（例如根据多年经验本能地调整船舶的油门或舵，而无需回想每个步骤）。*(注意：请确保您的举例与驾驶台任务直接相关，以保持读者对海事相关性的关注。)*
* **潜意识（半自动）：** 像打结或监控雷达萤幕等活动需要极少的意识注意力，在完全意识之下运作（例如在多工处理的同时保持船舶航向，允许在未经充分斟酌的情况下进行快速调整）。*(建议：可以指出「半自动」在压力下可能会变得模糊；船员可能会过度依赖自动化，或者在需要关键注意力时未能充分利用自动化。)*
* **有意识（长期陈述性记忆）：** 像紧急操纵或应对火灾等深谋远虑的任务需要高度集中的注意力，利用长期陈述性记忆来确保首次尝试即正确执行步骤（例如在突发风险中遵循 COLREG 避碰规程）。*(这是一个很好的锚点；您可以添加一个您在培训中发现有效的具体演练，以使概念更具体。)*
人类的有意识大脑通常只能在短期记忆中同时处理 7±2 个项目（米勒法则 Miller’s Law；有些人考虑到干扰因素则采用 5±2）。超出此容量的任务（例如在风、流和附近有多艘船舶的繁忙水域进行靠泊）需要结构化的程序，将复杂性拆解为循序渐进的步骤。当程序无法应对累积的挑战时（例如连锁系统故障），必须投入额外的资源——如增加船员、专用工具或自动化设备——以减轻认知负荷并防止因负荷过载引发的疏失。
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### 7.2 记忆与人航要素图表解析 (Memory and Human Element Chart)
本节透过记忆过程的视角探讨主要的人为疏失类型，并建立在 7.1 的认知框架之上。该图表（如图 7-01 所示）根据记忆失效（短期记忆 STM、长期记忆 LTM、程序性记忆和陈述性记忆）如何与情感、注意力及技能因素相互作用，对疏失进行分类。每个类型都结合海事案例与缓减策略进行剖析，以强调其对安全的影响。
#### 知识型疏失：常被轻描淡写为「好笑」的错误 (Knowledge-Based Errors)
知识型疏失经常被轻描淡写地当成幽默的笑话，但这忽视了它们根植於短期记忆（STM）的缺口或向长期记忆（LTM）转移不完整的事实。我们可能会对某人笨拙地执行新学程序的 STORIES 一笑了之，然而我们现在轻松掌握的每一项技能都曾是陌生的。这种幽默往往源於「后见之明偏误（hindsight bias）」，即我们在内化了正确流程后，回过头来看会觉得当初的错误显而易见。
##### 案例：船上紧急情况下的昂贵代价
船长正在协调应变小组：紧急灭火队、机舱支援组和外部联络组。船长指示值班航行员（OOW）：「向主管机关报告事故，并警告附近船舶注意风险。」在恐慌中，OOW 抓起 VHF 频道 16 并广播：「Mayday, Mayday, Mayday! 本船为 M.V. ___，船上发生火灾与爆炸！」船长急忙纠正：「你在干什么？我们又没有要沉船——改用『Sécurité, Sécurité, Sécurité』！」
这混淆凸显了一个关键的区别：
* **「Mayday」** 专门用於即刻性、危及生命的紧急情况（如沉没或严重人员伤亡）。
* **「Sécurité」** 用於安全警告（如已控制住但仍构成航行风险的火灾）。
OOW 因压力与培训不足而引发的错误，展示了短期记忆中根深蒂固（但海员极少使用）的词汇如何导致错误。透过重复演练，程序会变成习惯，从而减少恐慌并实现自动、正确的反应。
#### 情感驱动的违规及其后果 (On Emotional Driven Violations)
人类常因情感冲动而将违规行为合理化，尽管在认知上意识到了风险却仍继续进行——这是一种违规（violation）的形式。这涉及明知是害行为却将其合理化为可接受（例如在家庭紧急情况下超速赶往医院，或为了赶交期而绕过安全规程）。违规行为优先考虑短期情感需求而非长期风险，其结果从轻微处罚到酿成大祸不等。诸如狂喜（增加鲁莽行为）或悲伤（降低动力）等情感状态会放大这种倾向，往往反映了根深蒂固的性格特徵或潜意识本能。
##### 破坏行为：违规的极端表现 (Sabotage: The Extreme End)
当违规行为出自恶意时，就会升级为破坏行为（sabotage），其严重程度取决於目的：
* **高风险破坏：** 故意弄沉船舶以诈领保险金。
* **低风险破坏：** 弄湿甲板以延误油漆工程从而获得休息。
如果没有问责机制，随著情绪加剧，违规行为将变得常态化，从而引发更大的风险。
**透过适应性领导力遏制情感驱动的疏失：**
* **动机激励：** 将个人价值观与组织目标相结合（例如培养对安全纪录的自豪感），以激发自律合规。
* **双向影响：** 提倡双向领导力，让下属能够对同侪和上级问责（例如对不安全的指令提出质疑）。
* **文化融合：** 将相互问责嵌人为核心特徵，从而实现对共同安全愿景的集体坚守。
#### 注意力相关疏失：「无心之过/失误」(Attention-Related Errors: "Slip")
失误（Slip）是指尽管个人先前具备相应能力，但在执行例行任务时因注意力暂时集中不集中而发生的错误。这些并非源於懒惰，而是源於大脑的认知局限，例如短期记忆 7±2 个项目的容量（依据米勒法则）。当神经讯号在程序性记忆路径中「短路」时就会发生失误，从而打乱自动化动作。
它们通常在执行过程中显现，例如动作中途停顿（例如伸手去关火，却意识到自己原本是想去拿水）。海事案例包括在多工处理时关错了气阀，或在长时间值班后放错了航行控制设备。疲劳或注意力分散（例如船员在长途值班期间失去焦点）都会引发失误，而在高风险环境中，这些失误可能会升级为灾难——例如传达错误的舵令，可能直接导致碰撞或坐底。
**透过以下方式减少失误：**
* 透过充分休息和任务轮换来防止身体疲劳，避免精神过载。
* 严格遵守休息时间以保持专注。
* 透过有意义的认可来培养内在动机，即使是在重复性的岗位上。
* 针对关键任务实施检查表、警报系统或双人覆核制（Buddy system）。
#### 技能型疏失与能力不足 (Skill-Based Errors and Incompetence)
失误（Slip）是指尽管个人先前具备相应能力，但在执行例行任务时因注意力暂时集中不集中而发生的错误。失误并非源於懒惰，而是源於大脑的认知局限，包括短期记忆 7±2 个项目的容量限制（米勒法则）。当程序性记忆路径中的讯号发生短暂短路时，就会发生失误，打乱自动化动作。
在执行中，失误可能表现为动作中途的停顿（例如伸手去关火，却意识到自己原本是想去拿水）。在船上，海事案例包括在多工处理时关错了气阀，或在长时间值班后放错了航行控制设备。疲劳或注意力分散（如船员在漫长的值班中失去焦点）可能会引发失误，而在高风险环境中，它们可能会升级为灾难——例如传达错误的舵令，进而可能导致碰撞或坐底。
#### 案例研究：当技能缺口引发灾难 (Case Studies: When Skill Gaps Lead to Catastrophe)
这些真实世界的案例说明了技能型疏失——往往因规程在长期记忆（LTM）中的巩固存在缺口以及情感驱动的决策而加剧——如何最终演变成灾难。在高风险的海事环境中，当培训未能填补适应性技能的缺口时，即使是经验丰富的领导者也可能会犯错。虽然没有任何培训计画能完全复制真实世界的混乱——那里数百人的生命悬於一线且时间极其紧迫——但结构化的演练可以培养有效应对所需的直觉。
##### 歌诗达协和号灾难 (Costa Concordia Disaster, 2012)
在义大利海岸附近邮轮「歌诗达协和号」坐底并倾覆期间，船长法兰西斯科・斯凯蒂诺（Francesco Schettino）过早弃船，事后声称自己在船身突然倾斜时「滑落」进了救生艇。他未能优先组织乘客疏散——这是核心的领导技能——导致了 32 人死亡。调查揭示了航行错误、危机管理不善以及情感驱动的失误，凸显了在压力下紧急规程的长期记忆（LTM）未经巩固如何削弱专业技术能力。
##### 世越号客轮沉没事故 (Sewol Ferry Sinking, 2014)
在韩国「世越号」客轮沉没的悲剧中，船长李准锡抛弃了船舶，将数百名乘客（主要是高中生）困在甲板下方。在超载和结构缺陷的情况下发生的这一弃船行为，导致了 304 人死亡，并凸显了危机应对中的严重缺陷。船长的行为归因於培训不足、情绪失控以及未能将规程内化至长期记忆（LTM）中，从而让恐慌压倒了理性决策。
##### 对比：2013 年波士顿马拉松爆炸案中的有效应对 (2013 Boston Marathon Bombing)
上述两个海事案例说明了长期记忆（LTM）巩固不足和情感驱动的决策如何在高风险情况下侵蚀良好的技术技能。相反，对 2013 年波士顿马拉松爆炸案的应对展示了透过严格培训建立起来的适应性直觉的好处。第一应变人员——尽管面对混乱、大量伤亡和时间压力——进行了有效的协调、分诊伤患，并以最小的额外伤害巩固了现场安全。这个非海事案例表明，结构化演练如何能够深化程序性记忆，使人们即使在模拟无法完全复制现实的情况下，也能采取冷静、直觉的行动。
这些事件表明，如果没有刻意练习和心理韧性培训，技能缺口将持续存在。为减缓此类疏失，海事组织应实施符合 IMO STCW 规范的演练，模拟不断升级的混乱情境、融入情商（EQ）组成部分，并包含事后检讨（debriefs）。透过重复和适应性情境来培养长期记忆，船员可以更好地应对不可预测的情况，从而降低灾难风险。
---
### 第七章 各级人员的人为疏失 (Chapter 7 Human Errors Across All Ranks)
鉴於海事产业独特且恶劣的作业环境，海上事故往往被归因於不可避免的必然。诸如恶劣天气（暴风雨、巨浪、强风）、航行危险（浅水区、航行盲区、吃水限制），以及船舶本身的物理局限性（庞大的体积、迟缓的操纵性、超重货物带来的惯性动能）等挑战，统称为不可抗力（force majeure）——即考验船员与设备的不可避免之自然力量。面对海上如此多的变数，理论上是无法达到「零事故」纪录的。
然而，这些挑战并不代表人类束手无策。正如一位液化天然气（LNG）船公司的经理对其继任者所建议的，约有 90% 的海事事故源於人为因素：其中约 60% 来自直接疏失（误判或程序失误），30% 来自间接的人为要素问题（培训不足或组织文化问题）。对於 LNG 船这类高风险船舶而言——如桑吉号（Sanchi）碰撞等悲剧所警示——即使是微小的疏失也可能演变成灾难性的后果。虽然其他船型或许能承受偶发的小事故，但根植於人为疏失的事件对所有海事领域均构成普遍的威胁。
#### 疏失的文化建构 (The Cultural Construction of Error)
疏失的概念并非生来固有的，而是由社会与文化所建构。图 7-01 展示了与人为疏失相关的六个认知要素——即注意力、记忆力和决策等大脑功能的基本层面。当其中任何一项出现偏差（例如因注意力不集中或风险评估失误），就可能发生错误或违规行为，且往往需要耗费大量资源才能纠正。
文化规范进一步塑造了人们对疏失的看待与容忍程度。在某些社会中，对成年子女提供长期支持被视为理所当然的义务；而在其他社会中，这可能被视为过度溺爱。在极端的文化或意识形态背景下，外人视为错误的行为（例如被冠上道德崇高名义的高风险行为）可能在特定群体内部被常态化，从而导致巨大的牺牲。在海事环境中，船员因工作场所文化而形成的根深蒂固的例行公事或习惯，可能会掩盖风险，使偏离规范的行为看起来毫无问题。文化扮演著群体「集体记忆」的角色，使原本可能被标记为危险的行为变得合理化。
#### 船上海事文化的缺口 (Gaps in Onboard Maritime Culture)
当前的船上海事文化揭示了基础安全实务中的重大缺口，营造出一个危险的环境。基本技能（例如严谨的目视了望程序与熟练的雷达航行）已在整个行业中逐渐退化。尽管持有合格证书，许多值班航行员（OOW）和船长的准备工作仍未达标准，缺乏完整的情境意识。由於麻痹大意（complacency）以及「其他人也是这样操作」的心态，船员和公司往往无视这些风险——即使已有大量的出版物、指南和模拟器培训课程可供利用。
令人担忧的是，即使人员获得了适当的技能与经验，人类易犯错的本质依然存在。疲劳、过度自信或根深蒂固的习惯等因素都会削弱警觉性，导致关键时刻发生疏失。这反映了更广泛的「风险常态化」文化：当不良做法成为日常例行公事时，它们就不再被视为偏离规范。如果没有积极地去培养责任感、正念与持续改进，可预防的事故循环将会持续下去。
#### 缓减建议 (Recommendations for Mitigation)
为解决这些人为因素，海事组织应优先开展符合 IMO 标准的「人为要素（Human Element）」培训，包括疲劳管理（依据 STCW 公约）以及结合目视、雷达和自动化工具（如 AIS 和 ARPA）的复合技能。鼓励建立不互相指责的「公正文化（Just Culture）」以促进错误通报，定期进行驾驶台团队模拟演练，并开展文化审计以挑战麻痹大意的现象。透过整合这些做法，业界可以降低 90% 的人为疏失统计数据，朝向更安全的作业迈进。
---
### 7.1 人为疏失：决策过程中的个人疏失 (Individual Errors in the Decision-Making)
人为疏失是人性中不可避免的一部分，但理解其类型、根本原因和缓减策略，对於包括海事作业在内的各个行业至关重要，以预防事故、提升安全性并优化效能。当行动或决策偏离预期结果时，就会发生这些疏失，这通常源於认知、情感或系统性的脆弱性。在驾驶台单个人的决策背景下，疏失可分为六种类型，每种类型都与不同的认知过程相关。这些如图 7-01 所示，并且经常在航行等高风险环境中相互作用。
1. **知识相关疏失 (Knowledge-Related Errors)：** 源於短期记忆（STM）的缺口或不准确，阻碍了对自身知识库的存取（例如在压力下遗忘关键程序，如在紧迫局面中忽视了避碰规则 COLREG）。
2. **情感相关疏失 (Emotion-Related Errors)：** 当高涨的情绪（如压力、恐惧或过度自信）压倒理性判断并干扰认知功能时发生（例如紧急情况下引发恐慌的决策，或平静航程中因麻痹大意而跳过安全检查）。
3. **注意力相关疏失 (Attention-Related Errors)：** 由注意力不集中引起，损害了执行任务所需的程序性记忆（例如在监控多个雷达目标时因分心、疲劳或注意力分散而遗漏航行警告）。
4. **技能相关疏失 (Skill-Related Errors)：** 源於应用与已学技能相关的长期记忆（LTM）时存在缺陷，通常是由於练习不足、培训过时或未能适应新程序所致。例如：
* 因不熟悉分道航行制（TSS）中更新的规程而误判船舶的操纵。
* 错误应用依据过时标准教授的避碰技巧，导致无效的转向。
5. **直觉相关疏失 (Intuition-Related Errors)：** 源於过度依赖透过习惯养成的自动化直觉思维（例如因对例行公事的盲目自信、时间紧迫或冲动的「突发奇想」决策，如在繁忙水域未经全面评估即改变航向，而跳过检查表步骤）。
6. **文化相关疏失 (Culture-Related Errors)：** 根植於文化或组织架构内的集体长期记忆中，其中被常态化的做法在群体内部被视为「正确」，但在更广泛的背景下可能构成疏失（例如同侪间对安全规程持麻痹大意态度，如在熟悉航线上容忍放松了望警觉）。
#### 图 7-01 记忆与人为要素图表 (Memory and Human Element Chart)
人类的记忆系统由三个核心部分组成：感官记忆（感官输入的短暂初始储存）、短期记忆（暂时保持与操作，常称为工作记忆）和长期记忆（知识与经验的永久储存）。认知过程可以是可言语化的（意识到的且可描述的）或非言语的（自动的与无意识的）。许多行动往往是在无意识中执行的，依赖程序性记忆（技能的肌肉记忆），而非需要意识解释的陈述性记忆（事实或情境知识）。这解释了为什么重复性的任务随著时间推移会变得自动化。
当在这种无意识模式下正确执行时，这些行动会形成有益的习惯——想想一位经验丰富的轮机员反射性地进行例行检查，从而提高效率与安全性。相反，当在无意识层面执行不当，则可能导致无意注意疏失（inattentional errors，例如因根深蒂固的麻痹大意而跳过关键安全步骤，可能在高风险的海事作业中引发疏忽）。*(注：在实际驾驶台作业中，「无意注意疏失」的概念可以更广泛，包括压力下的优先顺序混乱或漏掉交叉覆核。以您观察到的具体、重复出现的驾驶台情境来举例说明可能会有所帮助。)*
在此基础上，我们的认知努力在三个不同的层面上运作，每个层面都会影响任务的执行方式，以及在船舶驾驶台等动态环境中可能出现疏失的地方：
* **无意识（程序性记忆）：** 像走路或进食等任务依赖长期程序性记忆——在没有意识思考的情况下自动执行的习惯性动作（例如根据多年经验本能地调整船舶的油门或舵，而无需回想每个步骤）。*(注意：请确保您的举例与驾驶台任务直接相关，以保持读者对海事相关性的关注。)*
* **潜意识（半自动）：** 像打结或监控雷达萤幕等活动需要极少的意识注意力，在完全意识之下运作（例如在多工处理的同时保持船舶航向，允许在未经充分斟酌的情况下进行快速调整）。*(建议：可以指出「半自动」在压力下可能会变得模糊；船员可能会过度依赖自动化，或者在需要关键注意力时未能充分利用自动化。)*
* **有意识（长期陈述性记忆）：** 像紧急操纵或应对火灾等深谋远虑的任务需要高度集中的注意力，利用长期陈述性记忆来确保首次尝试即正确执行步骤（例如在突发风险中遵循 COLREG 避碰规程）。*(这是一个很好的锚点；您可以添加一个您在培训中发现有效的具体演练，以使概念更具体。)*
人类的有意识大脑通常只能在短期记忆中同时处理 7±2 个项目（米勒法则 Miller’s Law；有些人考虑到干扰因素则采用 5±2）。超出此容量的任务（例如在风、流和附近有多艘船舶的繁忙水域进行靠泊）需要结构化的程序，将复杂性拆解为循序渐进的步骤。当程序无法应对累积的挑战时（例如连锁系统故障），必须投入额外的资源——如增加船员、专用工具或自动化设备——以减轻认知负荷并防止因负荷过载引发的疏失。
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### 7.2 记忆与人航要素图表解析 (Memory and Human Element Chart)
本节透过记忆过程的视角探讨主要的人为疏失类型，并建立在 7.1 的认知框架之上。该图表（如图 7-01 所示）根据记忆失效（短期记忆 STM、长期记忆 LTM、程序性记忆和陈述性记忆）如何与情感、注意力及技能因素相互作用，对疏失进行分类。每个类型都结合海事案例与缓减策略进行剖析，以强调其对安全的影响。
#### 知识型疏失：常被轻描淡写为「好笑」的错误 (Knowledge-Based Errors)
知识型疏失经常被轻描淡写地当成幽默的笑话，但这忽视了它们根植於短期记忆（STM）的缺口或向长期记忆（LTM）转移不完整的事实。我们可能会对某人笨拙地执行新学程序的 STORIES 一笑了之，然而我们现在轻松掌握的每一项技能都曾是陌生的。这种幽默往往源於「后见之明偏误（hindsight bias）」，即我们在内化了正确流程后，回过头来看会觉得当初的错误显而易见。
##### 案例：船上紧急情况下的昂贵代价
船长正在协调应变小组：紧急灭火队、机舱支援组和外部联络组。船长指示值班航行员（OOW）：「向主管机关报告事故，并警告附近船舶注意风险。」在恐慌中，OOW 抓起 VHF 频道 16 并广播：「Mayday, Mayday, Mayday! 本船为 M.V. ___，船上发生火灾与爆炸！」船长急忙纠正：「你在干什么？我们又没有要沉船——改用『Sécurité, Sécurité, Sécurité』！」
这混淆凸显了一个关键的区别：
* **「Mayday」** 专门用於即刻性、危及生命的紧急情况（如沉没或严重人员伤亡）。
* **「Sécurité」** 用於安全警告（如已控制住但仍构成航行风险的火灾）。
OOW 因压力与培训不足而引发的错误，展示了短期记忆中根深蒂固（但海员极少使用）的词汇如何导致错误。透过重复演练，程序会变成习惯，从而减少恐慌并实现自动、正确的反应。
#### 情感驱动的违规及其后果 (On Emotional Driven Violations)
人类常因情感冲动而将违规行为合理化，尽管在认知上意识到了风险却仍继续进行——这是一种违规（violation）的形式。这涉及明知是害行为却将其合理化为可接受（例如在家庭紧急情况下超速赶往医院，或为了赶交期而绕过安全规程）。违规行为优先考虑短期情感需求而非长期风险，其结果从轻微处罚到酿成大祸不等。诸如狂喜（增加鲁莽行为）或悲伤（降低动力）等情感状态会放大这种倾向，往往反映了根深蒂固的性格特徵或潜意识本能。
##### 破坏行为：违规的极端表现 (Sabotage: The Extreme End)
当违规行为出自恶意时，就会升级为破坏行为（sabotage），其严重程度取决於目的：
* **高风险破坏：** 故意弄沉船舶以诈领保险金。
* **低风险破坏：** 弄湿甲板以延误油漆工程从而获得休息。
如果没有问责机制，随著情绪加剧，违规行为将变得常态化，从而引发更大的风险。
**透过适应性领导力遏制情感驱动的疏失：**
* **动机激励：** 将个人价值观与组织目标相结合（例如培养对安全纪录的自豪感），以激发自律合规。
* **双向影响：** 提倡双向领导力，让下属能够对同侪和上级问责（例如对不安全的指令提出质疑）。
* **文化融合：** 将相互问责嵌人为核心特徵，从而实现对共同安全愿景的集体坚守。
#### 注意力相关疏失：「无心之过/失误」(Attention-Related Errors: "Slip")
失误（Slip）是指尽管个人先前具备相应能力，但在执行例行任务时因注意力暂时集中不集中而发生的错误。这些并非源於懒惰，而是源於大脑的认知局限，例如短期记忆 7±2 个项目的容量（依据米勒法则）。当神经讯号在程序性记忆路径中「短路」时就会发生失误，从而打乱自动化动作。
它们通常在执行过程中显现，例如动作中途停顿（例如伸手去关火，却意识到自己原本是想去拿水）。海事案例包括在多工处理时关错了气阀，或在长时间值班后放错了航行控制设备。疲劳或注意力分散（例如船员在长途值班期间失去焦点）都会引发失误，而在高风险环境中，这些失误可能会升级为灾难——例如传达错误的舵令，可能直接导致碰撞或坐底。
**透过以下方式减少失误：**
* 透过充分休息和任务轮换来防止身体疲劳，避免精神过载。
* 严格遵守休息时间以保持专注。
* 透过有意义的认可来培养内在动机，即使是在重复性的岗位上。
* 针对关键任务实施检查表、警报系统或双人覆核制（Buddy system）。
#### 技能型疏失与能力不足 (Skill-Based Errors and Incompetence)
失误（Slip）是指尽管个人先前具备相应能力，但在执行例行任务时因注意力暂时集中不集中而发生的错误。失误并非源於懒惰，而是源於大脑的认知局限，包括短期记忆 7±2 个项目的容量限制（米勒法则）。当程序性记忆路径中的讯号发生短暂短路时，就会发生失误，打乱自动化动作。
在执行中，失误可能表现为动作中途的停顿（例如伸手去关火，却意识到自己原本是想去拿水）。在船上，海事案例包括在多工处理时关错了气阀，或在长时间值班后放错了航行控制设备。疲劳或注意力分散（如船员在漫长的值班中失去焦点）可能会引发失误，而在高风险环境中，它们可能会升级为灾难——例如传达错误的舵令，进而可能导致碰撞或坐底。
#### 案例研究：当技能缺口引发灾难 (Case Studies: When Skill Gaps Lead to Catastrophe)
这些真实世界的案例说明了技能型疏失——往往因规程在长期记忆（LTM）中的巩固存在缺口以及情感驱动的决策而加剧——如何最终演变成灾难。在高风险的海事环境中，当培训未能填补适应性技能的缺口时，即使是经验丰富的领导者也可能会犯错。虽然没有任何培训计画能完全复制真实世界的混乱——那里数百人的生命悬於一线且时间极其紧迫——但结构化的演练可以培养有效应对所需的直觉。
##### 歌诗达协和号灾难 (Costa Concordia Disaster, 2012)
在义大利海岸附近邮轮「歌诗达协和号」坐底并倾覆期间，船长法兰西斯科・斯凯蒂诺（Francesco Schettino）过早弃船，事后声称自己在船身突然倾斜时「滑落」进了救生艇。他未能优先组织乘客疏散——这是核心的领导技能——导致了 32 人死亡。调查揭示了航行错误、危机管理不善以及情感驱动的失误，凸显了在压力下紧急规程的长期记忆（LTM）未经巩固如何削弱专业技术能力。
##### 世越号客轮沉没事故 (Sewol Ferry Sinking, 2014)
在韩国「世越号」客轮沉没的悲剧中，船长李准锡抛弃了船舶，将数百名乘客（主要是高中生）困在甲板下方。在超载和结构缺陷的情况下发生的这一弃船行为，导致了 304 人死亡，并凸显了危机应对中的严重缺陷。船长的行为归因於培训不足、情绪失控以及未能将规程内化至长期记忆（LTM）中，从而让恐慌压倒了理性决策。
##### 对比：2013 年波士顿马拉松爆炸案中的有效应对 (2013 Boston Marathon Bombing)
上述两个海事案例说明了长期记忆（LTM）巩固不足和情感驱动的决策如何在高风险情况下侵蚀良好的技术技能。相反，对 2013 年波士顿马拉松爆炸案的应对展示了透过严格培训建立起来的适应性直觉的好处。第一应变人员——尽管面对混乱、大量伤亡和时间压力——进行了有效的协调、分诊伤患，并以最小的额外伤害巩固了现场安全。这个非海事案例表明，结构化演练如何能够深化程序性记忆，使人们即使在模拟无法完全复制现实的情况下，也能采取冷静、直觉的行动。
这些事件表明，如果没有刻意练习和心理韧性培训，技能缺口将持续存在。为减缓此类疏失，海事组织应实施符合 IMO STCW 规范的演练，模拟不断升级的混乱情境、融入情商（EQ）组成部分，并包含事后检讨（debriefs）。透过重复和适应性情境来培养长期记忆，船员可以更好地应对不可预测的情况，从而降低灾难风险。
售价 NT$ 300
Chapter 7 Human Errors Across All Ranks
Marine accidents are often framed as inevitable, given the uniquely harsh operational environment
of the maritime industry. Challenges such as extreme weather (storms, high waves, strong winds),
navigational hazards (shallow waters, blind navigation zones, draft restrictions), and the physical
limitations of vessels (massive size, sluggish maneuverability, momentum from ultra-heavy cargo) are
collectively described as force majeure—unavoidable natural forces that test both crew and equipment.
With so many variables at sea, a zero-accident record is, in theory, unattainable.
Yet these challenges do not render humans powerless. As one LNG-tanker company manager
advised his successor, approximately 90% of maritime accidents stem from human factors: about 60%
from direct errors (misjudgments or procedural lapses) and 30% from indirect human-element issues
(inadequate training or organizational culture). For high-risk vessels like LNG carriers—highlighted by
tragedies such as the Sanchi collision—even minor incidents can escalate into catastrophic
consequences. While other ship types may tolerate occasional mishaps, incidents rooted in human
error pose a universal threat across all maritime sectors.
The Cultural Construction of Error
Notions of error are not intrinsic; they are socially and culturally constructed. Figure 7-01 illustrates
six cognitive elements tied to human error—fundamental aspects of brain function such as attention,
memory, and decision-making. When any of these falter (for example, due to inattentiveness or flawed
risk assessment), errors or violations can occur, often requiring significant resources to rectify.
Cultural norms further shape how errors are perceived and tolerated. In some societies, extended
parental support for adult children is viewed as a natural obligation, while in others it may be seen as
overindulgence. In extreme cultural or ideological contexts, actions outsiders deem erroneous (for
example, high-risk behaviors framed as morally imperative) may be normalized within a group, leading
to substantial sacrifices. In maritime settings, seafarers’ ingrained routines or habits—shaped by
workplace culture—can obscure risks, making deviations appear unproblematic. Culture functions as a
group’s collective memory, legitimizing behaviors that might otherwise be flagged as hazardous.
Gaps in Onboard Maritime Culture
Current onboard maritime culture reveals critical gaps in foundational safety practices, creating a
perilous environment. Essential skills, such as disciplined visual lookout procedures and proficient
radar navigation, have eroded across the industry. Many Officers of the Watch (OOWs) and captains
operate with substandard preparedness, lacking full situational awareness despite holding
certifications. These risks often go unrecognized by crews and companies, justified by
complacencyand the mindset that “everyone else operates this way”—even with abundant publications,
guidelines, and simulator-based training available.
Alarmingly, human fallibility persists even when personnel acquire proper skills and experience.
Factors like fatigue, overconfidence, or ingrained habits can undermine vigilance, leading to errors in
critical moments. This reflects a broader cultural normalization of risk: when poor practices become
routine, they cease to be seen as deviations. Without proactive efforts to foster accountability,
mindfulness, and continuous improvement, the cycle of preventable accidents will continue.
Recommendations for Mitigation
To address these human factors, maritime organizations should prioritize IMO-aligned training on
the Human Element, including fatigue management (per the STCWConvention) and hybrid skills
blending visual, radar, and automated tools (e.g., AISand ARPA). Encourage a “just culture” that
promotes error reporting without blame, regular bridge-team simulations, and cultural audits to
challenge complacency. By integrating these practices, the industry can reduce the 90% human-error
statistic and move closer to safer operations.
7.1 Human Error: Individual Errors in the Decision-Making
Human error is an inevitable aspectof human nature, but understanding its types, root causes, and
mitigation strategies is essential across industries—including maritime operations—to prevent
accidents, enhance safety, and optimize performance. These errors arise when actions or decisions
deviate from intended outcomes, often due to cognitive, emotional, or systemic vulnerabilities. In the
context of a single individual’s decision-making on the bridge, errors can be categorized into six types,
each linked to distinct cognitive processes. These are illustrated in Figure 7-01 and often interplay in
high-stakes environments like navigation.
1. Knowledge-Related Errors: These arise from gaps or inaccuracies in short-term memory
(STM), hindering access to one’s knowledge base (e.g., forgetting a critical procedure under
pressure, such as overlooking a COLREG rule during a close-quarters situation).
2. Emotion-Related Errors: These occur when heightened emotions (e.g., stress, fear, or
overconfidence) overwhelmrational judgment, disrupting cognitive function (e.g., panic
induced decisions during emergencies or complacencyleading to skipped safety checks on a
calm voyage).
3. Attention-Related Errors: These are caused by lapsesin focus, impairing the use of
procedural memory needed for task execution (e.g., missing a navigation warning due to
distraction, fatigue, or divided attention while monitoring multiple radar targets).
4. Skill-Related Errors: These stem from deficiencies in applying long-term memory (LTM)
associated with learned skills, often due to inadequate practice, outdated training, or failure
to adapt to new procedures. For example:
Misjudging a vessel’s maneuver due to unfamiliarity with an updated protocol in a
traffic separation scheme (TSS).
Misapplying a collision-avoidance technique taught under outdated standards,
leading to an ineffective course alteration.
5. Intuition-Related Errors: These result from overreliance on automatic, intuitive thinking
ingrained through habit (e.g., skipping checklist steps due to misplaced confidence in routine,
rushed timelines, or impulsive “jump-out” decisions, such as altering course without full
assessment in dense traffic).
6. Culture-Related Errors: These are rooted in the collective long-term memory within a cultural
or organizational framework, where normalized practices are perceived as “correct” within
the group but may constitute errors in broader contexts (e.g., complacencytoward safety
protocols deemed acceptable by peers, such as tolerating reduced lookout vigilance on
familiar routes).
Figure 7 – 01 memory and human element chart
Human memory systems consist of three key components: sensory memory (the brief initial
storage of sensory input), short-term memory (temporary holding and manipulation, often called
working memory), and long-term memory (permanent storage of knowledge and experiences).
Cognitive processes can be verbalizable (conscious and describable) or non-verbal (automatic and
unconscious). Actions are often performed unconsciously, relying on procedural memory (muscle
memory for skills) rather than conscious explanation, which engages declarative memory (factual or
contextual knowledge). This explains why repeated tasks tend to become automated over time.
When executed correctly in this unconscious mode, these actions form beneficial habits—think of
a seasoned engineer performing routine engine checks reflexively, enhancing efficiency and safety.
Conversely, when performed incorrectly at an unconscious level, they can lead to inattentional errors
(for example, skipping a critical safety step due to ingrained complacency, potentially causing
oversights in high-stakes maritime operations). (Note: In real bridge operations, “inattentional error” can
be broader, including mis-prioritization or missed cross-checks under pressure. It might be helpful to
illustrate with a concrete, recurring bridge scenario you’ve observed.)
Building on this, our cognitive efforts operate at three distinct levels, each influencing how tasks
are performed and where errors may arise in dynamic environments like a ship’s bridge:
Unconscious (Procedural Memory)
Tasks such as walking or eating rely on long-term procedural memory—habitual actions executed
automatically without conscious thought (e.g., adjusting a ship’s throttle or rudder instinctively based on
years of experience, without recalling every step). (Caution: ensure your examples tie directly to bridge
tasks to maintain the reader’s focus on maritime relevance.)
Subconscious (Semi-Automatic)
Activities like tying knots or monitoring radar screens require minimal conscious attention,
operating just below full awareness (e.g., maintaining a vessel’s course while multitasking, allowing
quick adjustments without full deliberation). (Consider noting that “semi-automatic” can blur under
stress; crews may either over-rely on automation or underutilize it when critical attention is needed.)
Conscious (Long-Term Declarative Memory)
Deliberate tasks such as emergency maneuvers or fire responses demand focused attention,
drawing on long-term declarative memory to execute steps correctly on the first attempt (e.g., following
a collision-avoidance protocol under COLREGsduring a sudden risk). (This is a strong anchor; you
might add a specific drill you’ve found effective in training to ground the concept.)
The conscious mind can typically handle 7±2 items in short-term memory simultaneously (Miller’s
Law; some apply 5±2 to account for distractions). Tasks that exceed this capacity (for example, docking
in heavy traffic with wind, current, and multiple nearby vessels) require structured procedures that
break complexity into sequential steps. When procedures fail to address cumulative challenges (e.g.,
cascading system failures), additional resources—such as extra crew, specialized tools, or automation
—must be deployed to reduce cognitive load and prevent overload-induced errors.
7.2 memory and human element chart
This section explores key human error types through the lens of memory processes, building on
the cognitive frameworks in 7.1. The chart (as illustrated in Figure 7-01) categorizes errors based on
how memory failures—short-term memory (STM), long-term memory (LTM), procedural memory, and
declarative memory—interact with emotional, attentional, and skill-based factors. Each type is
examined with maritime examples and mitigation strategies to highlight their impact on safety.
Knowledge - based Errors: Often Dismissed as "Amusing"
Knowledge-based errors are frequently trivialized as humorous anecdotes, but this overlooks their
roots in gaps in STM or incomplete transfer to LTM. We may laugh at stories of someone fumbling a
newly learned procedure, yet every skill we now perform effortlessly was once unfamiliar. The humor
often stems from hindsight bias, where we retroactively view the error as obvious after internalizing the
correct process.
####### Example: A Costly Mistake During a Shipboard Emergency
The Master coordinates response teams: an emergency firefighting squad, an engine
support group, and external communications. The Master orders the OOW, “Report the
incident to authorities and warn nearby vessels of risks.” In a panic, the OOWgrabs the VHF
on Channel 16 and broadcasts: “Mayday, Mayday, Mayday! This is M.V.
—fire
and explosion onboard!” The Master corrects urgently: “What are you doing? We’re not sinking
—use ‘Sécurité, Sécurité, Sécurité’!”
This confusion highlights a critical distinction:
Mayday” is reserved for immediate, life-threatening emergencies (e.g., sinking or critical
casualties).
“Sécurité” is for safety warnings (e.g., a contained fire posing navigational risks).
The OOW’s error, triggered by stress and incomplete training, shows how ingrained knowledge in
STM (rarely used mariner terms) can lead to mistakes. Through repeated drills, procedures become
habitual, reducing panic and enabling automatic, correct responses.
On Emotional Driven Violations and Their
Consequences
Humans often rationalize rule-breaking due to emotional impulses, proceeding despite cognitive
awareness of the risks—a form of violation. These involve knowingly engaging in harmful behavior
while justifying it as acceptable (e.g., speeding to a hospital during a family emergency or bypassing
safety protocols to meet deadlines). Violations prioritize short-term emotional needs over long-term
risks, with outcomes ranging from minor penalties to catastrophes. Emotional states like euphoria
(increasing recklessness) or sadness (reducing motivation) amplify this propensity, often reflecting
ingrained personality traits or subconscious instincts.
Sabotage: The Extreme End of Violations
When violations arise from malicious intent, they escalate to sabotage, with severity depending on
goals:
High-stakes sabotage: Deliberately sinking a vessel for insurance fraud.
Low-stakes sabotage: Wetting a deck to delay painting and gain rest.
Without accountability, violations normalize, encouraging greater risks as emotions intensify.
Curb emotional-driven errors through adaptive leadership:
Motivation: Inspire compliance by aligning personal values with organizational goals (e.g.,
fostering pride in safety records).
Upward/Downward Influence: Promote bidirectional leadership, where subordinates hold
peers and superiors accountable (e.g., questioning unsafe orders).
Cultural Integration: Embed mutual accountability as a core trait, enabling collective
adherence to shared safety visions.
Attention related Errors : “Slip”
A slip is an error occurring due to momentary lapsesin attention during routine tasks, despite the
individual's prior competence. These do not result from laziness but from the brain's cognitive limits,
such as the 7±2 item capacity of short-term memory (per Miller's Law). Slipsarise when neuronal
signaling "short-circuits" in procedural memory pathways, disrupting automatic actions.
They often manifest during execution, such as pausing mid-movement (e.g., reaching to turn off
the stove but realizing you intended to get water). Maritime examples include shutting the wrong gas
valve while multitasking or misplacing a navigation control after extended watchkeeping. Fatigue or
disengagement (e.g., a child dropping utensils due to lack of interest) can trigger slips, and in high-risk
settings, they can lead to disasters like miscommunicating a helmorder, causing a collision or
grounding.
Reduce slipsby: :
Preventing physical fatigue through adequate rest and task rotation to avoid mental overload.
Respecting rest periods to maintain focus.
Fostering intrinsic motivation via meaningful recognition, even in repetitive roles.
Implementing checklists, alarms, or buddy systems for critical tasks.
Skill - Based Errors and Incompetence
A slip is an error born from momentary lapsesin attention during routine tasks, despite the
individual’s prior competence. Slipsdo not stem from laziness but from the brain’s cognitive limits,
including the 7±2 item capacity of short-term memory (Miller’s Law). Slipsoccur when signals in
procedural memory pathways briefly short-circuit, disrupting automatic actions.
In execution, slipsmay appear as a pause mid-movement (for example, reaching to turn off the
stove but realizing you intended to fetch water). On a ship, maritime examples include turning off the
wrong gas valve while multitasking or misplacing a navigation control after extended watchkeeping.
Fatigue or disengagement (such as a crew member losing focus during a long watch) can trigger slips,
and in high-risk settings they can escalate to disasters—miscommunicated helmorders, for instance,
potentially leading to collision or grounding.
Case Studies: When Skil Gaps Lead to Catastrophe
These real-world examples illustrate how skill-based errors—often compounded by gaps in long
term memory (LTM) consolidation of protocols and emotion-driven decision-making—can culminate in
disaster. In high-stakes maritime environments, even seasoned leaders may falter when training does
not bridge gaps in adaptive skills. While no program can perfectly replicate real-world chaos—where
hundreds of lives are at risk and time is relentlessly scarce—structured drills can cultivate the intuition
needed for effective responses.
Costa Concordia Disaster (2012)
During the grounding and capsizing of the cruise ship Costa Concordia off Italy, Captain Francesco
Schettino abandoned the vessel prematurely, later claiming he “fell” into a lifeboat amid the ship’s
sudden list. His failure to prioritize passenger evacuation—a core leadership skill—contributed to 32
deaths. Investigations revealed navigational errors, poor crisis management, and emotion-driven
lapses, underscoring how unconsolidated LTM for emergency protocols can undermine technical
proficiency under pressure.
Sewol Ferry Sinking (2014)
In the tragic sinking of the South Korean ferry Sewol, Captain Lee Joon-seok deserted the ship,
leaving hundreds of passengers (mostly high school students) trapped below deck. This abandonment,
amid overloading and structural failures, resulted in 304 deaths and highlighted significant
shortcomings in crisis response. The captain’s actions were attributed to insufficient training, emotional
overwhelm, and a failure to internalize protocols in LTM, allowing panic to override rational decision
making.
Contrast: Effective Response in the 2013 Boston Marathon Bombing
Both maritime cases illustrate how inadequate LTM consolidation and emotion-driven decisions
can erode well-developed technical skills in high-stakes situations. In contrast, the response to the
2013 Boston Marathon bombing demonstrated the benefits of adaptive intuition built through rigorous
training. First responders—despite chaos, mass casualties, and time pressure—coordinated effectively,
triaged victims, and secured the area with minimal additional harm. This non-maritime example shows
how structured drills can engrain procedural memory, enabling calm, intuitive actions even when
simulations cannot fully replicate reality.
These incidents show that skill gaps endure without deliberate practice and emotional resilience
training. To mitigate such errors, maritime organizations should implement IMO STCW-compliant drills
that simulate escalating chaos, incorporate emotional intelligence components, and include post-event
debriefs. By fostering LTM through repetition and adaptive scenarios, crews can better handle the
unpredictable, reducing the risk of catastrophe.
Marine accidents are often framed as inevitable, given the uniquely harsh operational environment
of the maritime industry. Challenges such as extreme weather (storms, high waves, strong winds),
navigational hazards (shallow waters, blind navigation zones, draft restrictions), and the physical
limitations of vessels (massive size, sluggish maneuverability, momentum from ultra-heavy cargo) are
collectively described as force majeure—unavoidable natural forces that test both crew and equipment.
With so many variables at sea, a zero-accident record is, in theory, unattainable.
Yet these challenges do not render humans powerless. As one LNG-tanker company manager
advised his successor, approximately 90% of maritime accidents stem from human factors: about 60%
from direct errors (misjudgments or procedural lapses) and 30% from indirect human-element issues
(inadequate training or organizational culture). For high-risk vessels like LNG carriers—highlighted by
tragedies such as the Sanchi collision—even minor incidents can escalate into catastrophic
consequences. While other ship types may tolerate occasional mishaps, incidents rooted in human
error pose a universal threat across all maritime sectors.
The Cultural Construction of Error
Notions of error are not intrinsic; they are socially and culturally constructed. Figure 7-01 illustrates
six cognitive elements tied to human error—fundamental aspects of brain function such as attention,
memory, and decision-making. When any of these falter (for example, due to inattentiveness or flawed
risk assessment), errors or violations can occur, often requiring significant resources to rectify.
Cultural norms further shape how errors are perceived and tolerated. In some societies, extended
parental support for adult children is viewed as a natural obligation, while in others it may be seen as
overindulgence. In extreme cultural or ideological contexts, actions outsiders deem erroneous (for
example, high-risk behaviors framed as morally imperative) may be normalized within a group, leading
to substantial sacrifices. In maritime settings, seafarers’ ingrained routines or habits—shaped by
workplace culture—can obscure risks, making deviations appear unproblematic. Culture functions as a
group’s collective memory, legitimizing behaviors that might otherwise be flagged as hazardous.
Gaps in Onboard Maritime Culture
Current onboard maritime culture reveals critical gaps in foundational safety practices, creating a
perilous environment. Essential skills, such as disciplined visual lookout procedures and proficient
radar navigation, have eroded across the industry. Many Officers of the Watch (OOWs) and captains
operate with substandard preparedness, lacking full situational awareness despite holding
certifications. These risks often go unrecognized by crews and companies, justified by
complacencyand the mindset that “everyone else operates this way”—even with abundant publications,
guidelines, and simulator-based training available.
Alarmingly, human fallibility persists even when personnel acquire proper skills and experience.
Factors like fatigue, overconfidence, or ingrained habits can undermine vigilance, leading to errors in
critical moments. This reflects a broader cultural normalization of risk: when poor practices become
routine, they cease to be seen as deviations. Without proactive efforts to foster accountability,
mindfulness, and continuous improvement, the cycle of preventable accidents will continue.
Recommendations for Mitigation
To address these human factors, maritime organizations should prioritize IMO-aligned training on
the Human Element, including fatigue management (per the STCWConvention) and hybrid skills
blending visual, radar, and automated tools (e.g., AISand ARPA). Encourage a “just culture” that
promotes error reporting without blame, regular bridge-team simulations, and cultural audits to
challenge complacency. By integrating these practices, the industry can reduce the 90% human-error
statistic and move closer to safer operations.
7.1 Human Error: Individual Errors in the Decision-Making
Human error is an inevitable aspectof human nature, but understanding its types, root causes, and
mitigation strategies is essential across industries—including maritime operations—to prevent
accidents, enhance safety, and optimize performance. These errors arise when actions or decisions
deviate from intended outcomes, often due to cognitive, emotional, or systemic vulnerabilities. In the
context of a single individual’s decision-making on the bridge, errors can be categorized into six types,
each linked to distinct cognitive processes. These are illustrated in Figure 7-01 and often interplay in
high-stakes environments like navigation.
1. Knowledge-Related Errors: These arise from gaps or inaccuracies in short-term memory
(STM), hindering access to one’s knowledge base (e.g., forgetting a critical procedure under
pressure, such as overlooking a COLREG rule during a close-quarters situation).
2. Emotion-Related Errors: These occur when heightened emotions (e.g., stress, fear, or
overconfidence) overwhelmrational judgment, disrupting cognitive function (e.g., panic
induced decisions during emergencies or complacencyleading to skipped safety checks on a
calm voyage).
3. Attention-Related Errors: These are caused by lapsesin focus, impairing the use of
procedural memory needed for task execution (e.g., missing a navigation warning due to
distraction, fatigue, or divided attention while monitoring multiple radar targets).
4. Skill-Related Errors: These stem from deficiencies in applying long-term memory (LTM)
associated with learned skills, often due to inadequate practice, outdated training, or failure
to adapt to new procedures. For example:
Misjudging a vessel’s maneuver due to unfamiliarity with an updated protocol in a
traffic separation scheme (TSS).
Misapplying a collision-avoidance technique taught under outdated standards,
leading to an ineffective course alteration.
5. Intuition-Related Errors: These result from overreliance on automatic, intuitive thinking
ingrained through habit (e.g., skipping checklist steps due to misplaced confidence in routine,
rushed timelines, or impulsive “jump-out” decisions, such as altering course without full
assessment in dense traffic).
6. Culture-Related Errors: These are rooted in the collective long-term memory within a cultural
or organizational framework, where normalized practices are perceived as “correct” within
the group but may constitute errors in broader contexts (e.g., complacencytoward safety
protocols deemed acceptable by peers, such as tolerating reduced lookout vigilance on
familiar routes).
Figure 7 – 01 memory and human element chart
Human memory systems consist of three key components: sensory memory (the brief initial
storage of sensory input), short-term memory (temporary holding and manipulation, often called
working memory), and long-term memory (permanent storage of knowledge and experiences).
Cognitive processes can be verbalizable (conscious and describable) or non-verbal (automatic and
unconscious). Actions are often performed unconsciously, relying on procedural memory (muscle
memory for skills) rather than conscious explanation, which engages declarative memory (factual or
contextual knowledge). This explains why repeated tasks tend to become automated over time.
When executed correctly in this unconscious mode, these actions form beneficial habits—think of
a seasoned engineer performing routine engine checks reflexively, enhancing efficiency and safety.
Conversely, when performed incorrectly at an unconscious level, they can lead to inattentional errors
(for example, skipping a critical safety step due to ingrained complacency, potentially causing
oversights in high-stakes maritime operations). (Note: In real bridge operations, “inattentional error” can
be broader, including mis-prioritization or missed cross-checks under pressure. It might be helpful to
illustrate with a concrete, recurring bridge scenario you’ve observed.)
Building on this, our cognitive efforts operate at three distinct levels, each influencing how tasks
are performed and where errors may arise in dynamic environments like a ship’s bridge:
Unconscious (Procedural Memory)
Tasks such as walking or eating rely on long-term procedural memory—habitual actions executed
automatically without conscious thought (e.g., adjusting a ship’s throttle or rudder instinctively based on
years of experience, without recalling every step). (Caution: ensure your examples tie directly to bridge
tasks to maintain the reader’s focus on maritime relevance.)
Subconscious (Semi-Automatic)
Activities like tying knots or monitoring radar screens require minimal conscious attention,
operating just below full awareness (e.g., maintaining a vessel’s course while multitasking, allowing
quick adjustments without full deliberation). (Consider noting that “semi-automatic” can blur under
stress; crews may either over-rely on automation or underutilize it when critical attention is needed.)
Conscious (Long-Term Declarative Memory)
Deliberate tasks such as emergency maneuvers or fire responses demand focused attention,
drawing on long-term declarative memory to execute steps correctly on the first attempt (e.g., following
a collision-avoidance protocol under COLREGsduring a sudden risk). (This is a strong anchor; you
might add a specific drill you’ve found effective in training to ground the concept.)
The conscious mind can typically handle 7±2 items in short-term memory simultaneously (Miller’s
Law; some apply 5±2 to account for distractions). Tasks that exceed this capacity (for example, docking
in heavy traffic with wind, current, and multiple nearby vessels) require structured procedures that
break complexity into sequential steps. When procedures fail to address cumulative challenges (e.g.,
cascading system failures), additional resources—such as extra crew, specialized tools, or automation
—must be deployed to reduce cognitive load and prevent overload-induced errors.
7.2 memory and human element chart
This section explores key human error types through the lens of memory processes, building on
the cognitive frameworks in 7.1. The chart (as illustrated in Figure 7-01) categorizes errors based on
how memory failures—short-term memory (STM), long-term memory (LTM), procedural memory, and
declarative memory—interact with emotional, attentional, and skill-based factors. Each type is
examined with maritime examples and mitigation strategies to highlight their impact on safety.
Knowledge - based Errors: Often Dismissed as "Amusing"
Knowledge-based errors are frequently trivialized as humorous anecdotes, but this overlooks their
roots in gaps in STM or incomplete transfer to LTM. We may laugh at stories of someone fumbling a
newly learned procedure, yet every skill we now perform effortlessly was once unfamiliar. The humor
often stems from hindsight bias, where we retroactively view the error as obvious after internalizing the
correct process.
####### Example: A Costly Mistake During a Shipboard Emergency
The Master coordinates response teams: an emergency firefighting squad, an engine
support group, and external communications. The Master orders the OOW, “Report the
incident to authorities and warn nearby vessels of risks.” In a panic, the OOWgrabs the VHF
on Channel 16 and broadcasts: “Mayday, Mayday, Mayday! This is M.V.
—fire
and explosion onboard!” The Master corrects urgently: “What are you doing? We’re not sinking
—use ‘Sécurité, Sécurité, Sécurité’!”
This confusion highlights a critical distinction:
Mayday” is reserved for immediate, life-threatening emergencies (e.g., sinking or critical
casualties).
“Sécurité” is for safety warnings (e.g., a contained fire posing navigational risks).
The OOW’s error, triggered by stress and incomplete training, shows how ingrained knowledge in
STM (rarely used mariner terms) can lead to mistakes. Through repeated drills, procedures become
habitual, reducing panic and enabling automatic, correct responses.
On Emotional Driven Violations and Their
Consequences
Humans often rationalize rule-breaking due to emotional impulses, proceeding despite cognitive
awareness of the risks—a form of violation. These involve knowingly engaging in harmful behavior
while justifying it as acceptable (e.g., speeding to a hospital during a family emergency or bypassing
safety protocols to meet deadlines). Violations prioritize short-term emotional needs over long-term
risks, with outcomes ranging from minor penalties to catastrophes. Emotional states like euphoria
(increasing recklessness) or sadness (reducing motivation) amplify this propensity, often reflecting
ingrained personality traits or subconscious instincts.
Sabotage: The Extreme End of Violations
When violations arise from malicious intent, they escalate to sabotage, with severity depending on
goals:
High-stakes sabotage: Deliberately sinking a vessel for insurance fraud.
Low-stakes sabotage: Wetting a deck to delay painting and gain rest.
Without accountability, violations normalize, encouraging greater risks as emotions intensify.
Curb emotional-driven errors through adaptive leadership:
Motivation: Inspire compliance by aligning personal values with organizational goals (e.g.,
fostering pride in safety records).
Upward/Downward Influence: Promote bidirectional leadership, where subordinates hold
peers and superiors accountable (e.g., questioning unsafe orders).
Cultural Integration: Embed mutual accountability as a core trait, enabling collective
adherence to shared safety visions.
Attention related Errors : “Slip”
A slip is an error occurring due to momentary lapsesin attention during routine tasks, despite the
individual's prior competence. These do not result from laziness but from the brain's cognitive limits,
such as the 7±2 item capacity of short-term memory (per Miller's Law). Slipsarise when neuronal
signaling "short-circuits" in procedural memory pathways, disrupting automatic actions.
They often manifest during execution, such as pausing mid-movement (e.g., reaching to turn off
the stove but realizing you intended to get water). Maritime examples include shutting the wrong gas
valve while multitasking or misplacing a navigation control after extended watchkeeping. Fatigue or
disengagement (e.g., a child dropping utensils due to lack of interest) can trigger slips, and in high-risk
settings, they can lead to disasters like miscommunicating a helmorder, causing a collision or
grounding.
Reduce slipsby: :
Preventing physical fatigue through adequate rest and task rotation to avoid mental overload.
Respecting rest periods to maintain focus.
Fostering intrinsic motivation via meaningful recognition, even in repetitive roles.
Implementing checklists, alarms, or buddy systems for critical tasks.
Skill - Based Errors and Incompetence
A slip is an error born from momentary lapsesin attention during routine tasks, despite the
individual’s prior competence. Slipsdo not stem from laziness but from the brain’s cognitive limits,
including the 7±2 item capacity of short-term memory (Miller’s Law). Slipsoccur when signals in
procedural memory pathways briefly short-circuit, disrupting automatic actions.
In execution, slipsmay appear as a pause mid-movement (for example, reaching to turn off the
stove but realizing you intended to fetch water). On a ship, maritime examples include turning off the
wrong gas valve while multitasking or misplacing a navigation control after extended watchkeeping.
Fatigue or disengagement (such as a crew member losing focus during a long watch) can trigger slips,
and in high-risk settings they can escalate to disasters—miscommunicated helmorders, for instance,
potentially leading to collision or grounding.
Case Studies: When Skil Gaps Lead to Catastrophe
These real-world examples illustrate how skill-based errors—often compounded by gaps in long
term memory (LTM) consolidation of protocols and emotion-driven decision-making—can culminate in
disaster. In high-stakes maritime environments, even seasoned leaders may falter when training does
not bridge gaps in adaptive skills. While no program can perfectly replicate real-world chaos—where
hundreds of lives are at risk and time is relentlessly scarce—structured drills can cultivate the intuition
needed for effective responses.
Costa Concordia Disaster (2012)
During the grounding and capsizing of the cruise ship Costa Concordia off Italy, Captain Francesco
Schettino abandoned the vessel prematurely, later claiming he “fell” into a lifeboat amid the ship’s
sudden list. His failure to prioritize passenger evacuation—a core leadership skill—contributed to 32
deaths. Investigations revealed navigational errors, poor crisis management, and emotion-driven
lapses, underscoring how unconsolidated LTM for emergency protocols can undermine technical
proficiency under pressure.
Sewol Ferry Sinking (2014)
In the tragic sinking of the South Korean ferry Sewol, Captain Lee Joon-seok deserted the ship,
leaving hundreds of passengers (mostly high school students) trapped below deck. This abandonment,
amid overloading and structural failures, resulted in 304 deaths and highlighted significant
shortcomings in crisis response. The captain’s actions were attributed to insufficient training, emotional
overwhelm, and a failure to internalize protocols in LTM, allowing panic to override rational decision
making.
Contrast: Effective Response in the 2013 Boston Marathon Bombing
Both maritime cases illustrate how inadequate LTM consolidation and emotion-driven decisions
can erode well-developed technical skills in high-stakes situations. In contrast, the response to the
2013 Boston Marathon bombing demonstrated the benefits of adaptive intuition built through rigorous
training. First responders—despite chaos, mass casualties, and time pressure—coordinated effectively,
triaged victims, and secured the area with minimal additional harm. This non-maritime example shows
how structured drills can engrain procedural memory, enabling calm, intuitive actions even when
simulations cannot fully replicate reality.
These incidents show that skill gaps endure without deliberate practice and emotional resilience
training. To mitigate such errors, maritime organizations should implement IMO STCW-compliant drills
that simulate escalating chaos, incorporate emotional intelligence components, and include post-event
debriefs. By fostering LTM through repetition and adaptive scenarios, crews can better handle the
unpredictable, reducing the risk of catastrophe.
